A nonagenarian's vehicle to expound at nonspecific intervals on his opinions regarding politics-local to international, health care, life,society,and perhaps religion plus periodic vignettes about Plainfield N.J.
In addition to "blowing off",I am enjoying a second career as an amateur public advocate.

Monday, August 31, 2009

This segment will focus on the Insurance Companies including their captive HMO programs, to be followed next time with a brief evaluation of Medicare's problems.

Why do I consider the Insurance Companies the greatest villain in the Health Care Cost debacle' In part from years of experience from dealing with them as a physician, as a patent's parent, and for years as Medical Director of the Central Jersey Individual Physicians Association , several hundred doctors in all specialties. This cooperative group of physicians who used the hospitals in Union, Somerset, and Middlesex Counties in their practice, contracted fees for their services in the early HMO days, the late 70s and though the 80s with various insurance companies. Among the plans (many now defunct) were those operated by Cigna, Aetna, Sanus, New York Life and CoMed along with a few other smaller plans. That would be a book onto itself.

When I use the term Health Care Insurance I am not limiting it to individual policies but to a greater extent to include the HMOs, PPOs and other group plan products of the Industry.

There is little uniformity in the premium costs to the insured no matter what the plan is. Individual self insurers are charged excessively high premiums since they do not have the protection of a volume group sale. Rates rise rapidly for those over 50. It is a fact that the older you are the greater are the chances that there will be physician visits and hospital admissions.

Although risk related premiums are proper business practices as applicable for property or auto insurance. it can make protection prohibitive to the elderly who are not Medicare eligible. Even for those that are the cost of supplemental coverage exceeds their resources.

The rates for the captive plans (HMO etc.) varies greatly for different groups. The best deals are in large groups that can negotiate with different carriers. Plans provide through small employers are more costly because they do not have the leverage. There are many instances where a small employer must compromise on the plans offered to the employees where the later must pay an increased percentage of the premium in comparison to those belonging to large groups. In any case the costs must be passed on to the consumer in the item's price. This is a cost of health care that most of us do not consider.

I have previously alluded to the costs incur ed by the physician's office in complying with the third party's rules.

However to produce a supportive document not of my own imagination I am reproducing a portion of Nicholas D, Kristof OP-ED column in the 8/27/09 New York Times. Mr Potter was a former executive for Humana and later Cigna before retiring. I would urge you to read the whole column but what he is quoted as saying reflects all that I had to deal with. Read On;

Mr. Potter says he liked his colleagues and bosses in the insurance industry, and respected them. They are not evil. But he adds that they are removed from the consequences of their decisions, as he was, and are obsessed with sustaining the company’s stock price — which means paying fewer medical bills.

One way to do that is to deny requests for expensive procedures. A second is “rescission” — seizing upon a technicality to cancel the policy of someone who has been paying premiums and finally gets cancer or some other expensive disease. A Congressional investigation into rescission found that three insurers, including Blue Cross of California, used this technique to cancel more than 20,000 policies over five years, saving the companies $300 million in claims.

As The Los Angeles Times has reported, insurers encourage this approach through performance evaluations. One Blue Cross employee earned a perfect evaluation score after dropping thousands of policyholders who faced nearly $10 million in medical expenses.

Mr. Potter notes that a third tactic is for insurers to raise premiums for a small business astronomically after an employee is found to have an illness that will be very expensive to treat. That forces the business to drop coverage for all its employees or go elsewhere.

All this is monstrous, and it negates the entire point of insurance, which is to spread risk.

The insurers are open to one kind of reform — universal coverage through mandates and subsidies, so as to give them more customers and more profits. But they don’t want the reforms that will most help patients, such as a public insurance option, enforced competition and tighter regulation.

Insurers are notorious for post facto denying procedures. Usually there was some minor failure in paperwork or approval procedure that was the excuse.

The insurance industry developed a guideline used by all for determining the reimbursement for hospital stay. This guide is disease or procedure oriented and is based on allowed days of hospital care. This guideline included the infamousone 'hospital day" stay for an uncomplicated obstetrical delivery.Since hospital days were calculated to be from midnight to midnight, if a baby was delivered at 12:01 AM the mother's hospital stay was over at midnightthat day.

Popular outrage and legislative action made them change that one. But, prior to the legislation, either the mother was billed for at least two days or some hospital ate 24 hours. Of course the baby was billed separately and could stay extra days while the mother went home.

This has been a truncated overview why I consider this industry to be the greatest factor in the rapidly increased cost of health care in this country. Instead of applying the breaks to the rising health care costs, they have become the biggest contributors to that trend. No wonder they are the biggest proponents of the regional cooperatives and the biggest antagonists to any government run plan.

It was not without malice of forethought that the executives of the "Blues", which were originally formed as non-profits, transformed their units into renamed stock companies while awarding themselves large stock bonuses during the transformation.

Sunday, August 30, 2009

1-Why Health Care Reform may fail;Article in Star Ledger 8/28/09; Rep.Pete Stark of California and extreme liberal blasted the centralist group of Democrats known as the 'Blue Democrats" as being brain dead since they oppose a federal run alternate insurance program with reimbursement at Medicare level.The Blues favor a competitive option rum by private insurers with some federal subsidy.

That is an option that the insurance companies like since it increases the number of policy holders. It also could be acceptable to the Republicans. Without the "Blues" vote any plan is dead.

2- The cost of Medicare Part D-the drug plan- will go up under the proposed house bill with the elimination of the doughnut clause. For those seniors whose drug costs are greater than $2800,00 annually their net cost will drop. Since the plan will be mandatory and might be expanded to include all age groups, the 19-50 year old group will be saddled with additional expense.

3-I am not being disrespectful, but there never has been a bigger spectacle than Ted Kennedy's two day funeral. He deserved a public burial including church services etc. He was a fortunate man who because of his name survived incidents for which others would have been punished. He never was under the pressure that forced others who deviated from accepted moral turpitude to give up their political career. Despite that he was not a politician but a true statesman and a great asset as a Senator. For that we mourn his passing.

I can remark about it because You and I paid for a large portion of it, including security especially for the President, the airplane to transport the casket to Washington, and the entire "Congressional funeral".

Cynically, he did push Michael Jackson off the over blown news coverage. Next week Michael and the weird case of the woman held as a love slave for 18 years will resume their place in the news. TV has changed our priorities from the days of newsprint.

4-Between blogging and daily tasks I have been reading a most interesting book that I found mentioned in a Times OP-ED column regarding the Darwin/Bible controversy especial in education circles. The book is ;The Evolution of God" by Wright. Since I have only progressed about one third of the way through it, I find it too early to draw any conclusions abut the author's contentions.. The scope of the book is the onset of religious belief in prehistoric man through the present day concept of God in today's three religions of the book. At this point I consider it "food for thought" with a final impression and/or acceptance to be reached after conclusion and reflection.

I believe that all reader thinkers will find this man's thesis interesting.

We continue examining the source of high health costs in the USA; the next contributor , and a important one is;

C-PHARMACEUTICALS ;

This segment consists of the producers and the retailers.

The retailers are the pharmacies and the "surgical supply outlets. The later I will return to when I discuss that industry as part of the inefficiency of cost control by Medicare.

Medical costs can be controlled at the retail outlet level. Most pharmacies are part of large retail chains in which filling prescriptions is a highly profitable but small element of the store mix. The pharmacy department by design is located in the rear of the store This encourages spontaneous purchases by the customer when they proceed to the pharmacy department to pick up prescriptions. The markup on various medications varies widely among different chains. Of course proprietary drugs are the costliest, but the profit margins on filling generic prescriptions are greater. This margin not price is why generics are actively promoted by the chains.

The manufacture and developer of new medications. Like any worker or business the pharmaceutical house is in business to earn money. The big companies who do research have a large investment in the producing of a new medication or therapeutic adjutant. Naturally they want to make enough money from every invention by research, as they can.

This is not the place to go into the costs in time, labor, false leads, testing for safety that go into the developing a unique medication for the market. Promoting and marketing the medication to the profession can also be costly. Also there is the unspoken risk of being the losing defendant in a class action law suit or suits if a drug after a period on the market is unexpectedly found to have detrimental effects.

It is true that in recent years the pharmaceutical manufactures have gone into great expense to publicly market their product. That is an element entering the final cost to the patient which should be prohibited.

We are bombarded to insist on generics. They only become available when the protective patents expire. Truly they cost much less to the consumer as well as the manufacture who has not had any expense in developing the drug.

Like the pirate counterfeiter who will copy a movie or music DVD and sell it through various outlets at prices well below the original, the generic drug manufacture is doing a similar but legal action. He is profiting on the work of someone else.

Perhaps this example would be clearer. Suppose you are an author and just had a best seller published. You would earn royalties from the publisher for each copy sold. You are now profiting from your labor, that is as things should be. But instead some off shore printer would without authorization reproduce your book, publish it and distribute it through cut rate outlets. You would not receive one penny from the sale of those copies. Would you consider that to be OK.

Translate the relationship of the generic manufacture and the company that developed the drug to the above and understand why the developer must make as much as possible from the early sales.

We have no knowledge of the markup the different retail chains put on the medications they sell. The price the consumer pays is determined by the cost to the seller plus his profit. Since generics cost the retail seller much less than the proprietary drug, the chain can increase the unit markup to a greater degree than the named medication and still undersell by a wide margin.

The savings from the various levels of the pharmaceutic industry could come from repricing medications after the developmental cost are recouped. A small amount in the price should be reserved for research and development of improved medications.

Indirectly related to the medicine costs in health care is the fact that although the generic may have the same chemical formula as the original there may be differences in therapeutic results that may be related to inert substances in the production of the consumer item. With have been recent become aware of quality control issues with some of the chemicals or drug production from China. If the results are compromised the ultimate treatment cost will be greater.

Saturday, August 29, 2009

I have deviated from my posting on the Health Care Bills by becoming "bogged" down in the wheres and whys of the costs to the individual and not continuing on to the employer/ employee responsibilities, We will get back to that later. Meanwhile to return to the real or demonized causes for our out of control health costs.

THE CULPRITS:

A-THE MEDICAL PROFESSION

Various elements of the Health Care continuum have been blamed for the high cost of US health care. A few I believe have been falsely made scape goats. Others have contributed and could be reasonably altered. One of the largest factor has been ignored.

As a long retired physician who has lived through the shift in medical practices from patient orientation to case treatment, I am aware that much of the blame leveled at the profession is nonsense. Yes, I am aware that many zealot's will dispute that statement. Please however hear me out.

Over the past few decades, although physician dollar reimbursement under Medicare has increased it has not kept pace with the cost of living. At the same time the actual value for many services has been lowered. Marshall Ackerman, a Washington DC orthopedist wrote in an OP ED article for the Times on August23 "In 1971 I was paid $1,000.00 for a total hip replacement. Today(2009) I would be paid $1,600.00 for the same service." With Surgery that is an all inclusive fee including all the necessary post operation visits. The surgeons do not and can not pad the bill, although in some contracts the wording only includes a normal post operative visit.

Likewise, the primary physician doesn't own CT or MRI scanners. His reimbursement for ECGs or Chest X-rays -which fewer are doing now because only the doctor or a licensed technician can operate the equipment- or Lab studies is so low that they are not economically worth the time or equipment, therefore it is outsourced. The cost for a physician to operate an office due to the need to have a large staff to keep up with the required paper work, communicating with the insurance carrier by phone or fax for approval for referrals or ordering diagnostic studies is unconscionable.

The role of doctor ownership of radiology or surgical facilities as a factor in increasing the costs has been overblown. Indeed present laws make unnecessary procedures at facilities in which an interest is held difficult and subject to legal action . The free standing surgical facilities must be licensed by the state. and subject to similar standards of a hospital facility. Indeed, if the doctor has a financial interest in the facility to which you have been referred, he is obligated to inform you. They can operate at lower costs probably due to better efficiency.

An example is the Surgery Center at the Watchung Circle. The hospital lost money operating it, even though patients and doctors found it preferable to go there than through the hospital rigmarole for same day surgery. The charges for similar procedures were much lower at the Center than in the Hospital. When the hospital sold it to the physicians who were using their in house facility as well as the Center it became profitable. The physician ownership result in a savings in cost to the patient and/or to the 3rd party payer.

Many of you may have already experienced the latest requirement for all doctors to have on record a photo ID of all patients"to cut down on insurance fraud". That include Medicare. The doctor may have treated the patient for 30 years but that patient must be treated in the same manner as one making his first visit. To fail to do so would subject the office to large fines if discovered during an unannounced survey visit. yes there is a threat of a police state.

There is little justification to place a major blame upon the physicians for the increase in heath care costs in as much as their operating expenses have increase at a rate greater than Medicare reimbursement. Yet Rep. Pete Stark would have the government reduce Medicare rates which are the standard used by the Insurance providers, to the equivalent of 'Bread and Water".

B-THE HOSPITALS ( EXCLUDING THE ER)

Although most patients enter the hospital via the Emergency Room (ER), an integral part of the hospital complex, I will treat it separately towards the end of this series.

Reimbursement for patient stay in hospitals is limited to case formula days. Every hospital admission is given a disease code base on the triage determination. The case code can be altered by the interpolation of modifying facts. That case code determine number of patient days allocated and what would b e the usual diagnostic procedures required. The reimbursement the hospital will receive is determined the moment the patient steps foot in the door.

To make sure that the regulations are adhere too, hospitals employ staffs of nurses and doctors who sole duty is to see that the standards are being followed, and if possible expedite discharge of the Patient as early as possible . Only by assuring that a patient doe not exceed his allotted hospital stay can the hospital survive. It could can gain if the patient leaves earlier, an unlikely occurrence, since the fee received is procedure or disease oriented. Thus under normal circumstances the hospital should not be a source of cost drain.

The hospital receives no further reimbursement if the patient becomes an outlier and exceeds that formula number of days. In most cases diagnostic studies are factored in the formula. This plus the under payment for Medicaid patients and bad insurance company contracts have contributed to the hospital's financial woes.

To counteract that loss the hospitals tend to increase markedly their stated charges to the uninsured. They developed a multi-tiered system. One fee accepted from the government. higher negotiated fees from various insurance carriers, and that charged to the individual which often was astronomically higher. The later charges must be adjusted in the future to equate with the usual and common fee paid the insurers.

I have not considered the constant need to upgrade diagnostic tools with expensive state of teh art equipment.

Hospitals are notoriously poor in understanding their operational costs. They bear part of the blame. On the other hand with their "contracts" with the third party payers negotiated under the threat of boycotting the hospital from the insurer's policy holders, the hospitals are an insignificant player.

We will continue with a look at; Pharmaceuticals, Insurance, Medical Supplies, the hospital emergency room, and Medicare operating controls as cost factors in health care.

Friday, August 28, 2009

Most of what I have written the past few days has been somewhat editorialized to express my convictions.

I am concerned that non of the proposals will endorse the need to provide adequate health care to all including the "illegals". Health care is not a "civil right" it is however a civic necessity. Better methods of delivery can be found without penalizing in various modalities the patient or the provider. Yes there must be controls to limit excessive costs, but the definite amount to finance the system will have to be between public use of insurance and application of designated tax monies.

One of the operational fallacies in health care insurance is that determining the cost is done by actuarial risk methods as are all other risk insurances. The greater the risk the higher the premium. Health insurance should not be financially equated with fire, auto, property, liability or workman's compensation insurance. By their nature the cost should be risk related.

AS things are now the present premium policy often prices it out of the reach of the population groups that needs it the most, the elderly and the extremely young, and those with preexisting health conditions .Indeed the older you get the more your insurance costs. Even Medicare is not exempt from that failure. Many elderly tend to drop all but basic Medicare coverage because of the cost.

Actuarial data can be developed for the population as a whole and the cost spread throughout the entire life span. Certainly the 19 to 50/60 age groups will be paying a higher premium. The overall premium for the so called low risk age group can be in part mitigated by offering an optional basic no frill policy at a low premium to this group. A federal tax supported subsidy of the difference between the overall premium and the basic policy premium from tax dollars would make up the difference. Private insurers can be under contract to operate the system as is presently the case for Medicare.

At the same time providers can be reimbursed at levels which for physicians would be commensurate with their years of training and present expertise. The unholy gap between the primary care physician and the specialist would be eliminated. The net result would be a return of the family doctor.

It is a given that Hospitals should be paid at a rate that would meet their operating costs, thus preventing Muhlenbergs of the future. This of course would mean strict cost controls , better accounting procedures and rational use of facilities.

There must be the elimination of the Albatross of law suits. Victims of obvious bad errors in treatment should be0reasonably compensated, but no one should be burdened by legal action against an unavoidable bad result. There may be the need of 'Referee" to determine the difference.

Thursday, August 27, 2009

Thursday,8/27/09, Dan Damon called our attention to another city problem. This one involves the Historic Districts.

Each district should be identified by name and the boundaries delineated.

Common building and property restrictions published

Unique restrictions for individual districts noted in the district description.

Procedures required for any building alterations; internal as well as external

Signed documentation that the property owner is aware of special requirements of the historic district

Signed affidavit by both Realtor and Purchaser at time of sale that conditions pertinent to the historic district have been explained to the buyer . To avoid confusion the affidavit should list restrictions.

The role of the Historic Commission, the Planning Board and the Zoning board before any construction permit is issued.

Who is responsible for enforcing the Historic District convents

Who can issue variances to the Historic District regulations and who must give final approval.

Who enforces the regulations unique to the Historic District.

What are the penalties for violating a Historic District.

Who will be held responsible for violations, Property owner, contractor. architect etc.; individual or all.

1-Everything above plus anything I have missed that is important should be collated into a readable single document readily available at the city clerk's office.

2-All such information should be posted on the city site at best under information pending a complete restructuring of the site to make it user friendly and informative.

I am sure all this is on file someware within the city hall walls but is it readily retrievable ? I ask this question since I am truly naive.

All of which brings me back to something I have advocated for years without success. All city ordinances should be reviewed, collated by subject into an available document. All Ordinances still on the books that have been supersede but not repealed or have become irresponsible due to passage of time and circumstances be formally revoked, or rewritten to be pertinent to the 21st Century.

I know this will cost money but I will bet a penny to a dollar that there is an available grant out there somewhere that will fund the project. Look for it.

While on the subject of the city's paper infrastructure, I believe that it is now the time to reorganize the administrative structure to provide for any new positions and eliminate redundant ones. Time to draw clear lines of responsibility and accounting (reporting).

If Plainfield is to revitalise itself the above is more important than the findings of any commission or study.

I have written about the Public Option which probably will never be implemented. That leaves two options; the first being the Regional Cooperatives and the other Single Payer mandatory insurance. If what follows is incoherent, that is because the whole $##&^^ process is at present.

The Regional Cooperative Plan creates an area or "regional agency" to which all health care providers must belong. The German model which Uwe Reinhardt promotes=see my post of a year ago

The Regional unit negotiates a reimbursement schedule with the areas providers as a group, IE: the area physicians association, the area hospitals etc. It is a take it or not participate situation.

There are separate means for covering the employed, those who have lost their job and those who have never been employed. Individuals whose income is above a certain level must purchase private insurance. The Cooperative pays the provider according the negotiate rates. Private insurers reimburse for their policy holders. again at a negotiated but higher rate.

Funding for "workers: is from deduction from their pay that amounts to with some slight variations by cooperative of approximately 14% of their wages; half of which is contributed by the employer. That would make the actual cost about 7%. The never employed are funded by a tax derived special fund. Another fund is in place for those who are temporarily unemployed.

In the German plan the primary physician does not treat patients in the hospital. Likewise except for certain specialties the hospital physician doesn't see the patient after discharge. This practice makes the patient a "case" not a person.

There will be variations of this plan from region to region.

The other alternative is the universal federal run health care system ,or single payer. Medicare is used as the example. It is said to be cost effective, but that is at the expense of mandated reimbursements to providers that have in effect decreased in "purchasing value dollars" over the years. The savings achieved by the plan bu this advantage has been lost in a greater degree by not preventing abuses in the system.

The net result is that in the past few years many physicians are opting out of Medicare and offering various forms of what is called "concierge practices". Although they do not participate in any insurance plans this seems to be a popular and profitable enterprise at the same time offering a return to the Saturday Evening Post "Family Doctor". The patients who can afford the service are ecstatic.

During the Presidential election campaign McCain said about 'Universal Health Care" : 'We will replace the inefficiency, irrationality, and uncontrolled costs of the current system with the inefficiency, irrationality, and uncontrolled costs of a government monopoly. We’ll have all the problems, and more, of private health care — rigid rules, long waits, and lack of choices, and risk degrading its great strengths and advantages including the innovation and life-saving technology that make American medicine the most advanced in the world."

Unfortunately despite the plaudits of the social reformers that statement will be 100% accurate.

Next post I will continue on this subject with some personal comments which I hope may produce some rational discussion and/or implementation.

Wednesday, August 26, 2009

Ted Kennedy died this am. The last of the Kennedy brothers, and shortly after his sister. There will be volumes of commentaries about this flamboyant person for the next few days.What will be interesting to see if Mass. changes its law to permit the appointment of a replacement instead of waiting to election time. Obama may need the vote for any Health Care Plan.If there is an appointment will the seat be treated as a family inheritance. Very possible

Undoubtedly there will be a tendency to deify him. Hopefully. people will remember that he was a mortal with all the faults and many virtues common to all of us.

One of the other major problems that have been causing much of the controversy has been the so-called Public Option. In its latest configuration it seems to be a government run insurance program that would be in competition to the commercial carriers. Supposedly the Public Option would be comparable to Medicare, or perhaps even Medicaid.

I have no idea what the exact provisions of the public option are in the house bill. I am forced to depend upon the writings of those who claim to have read all one thousand pages. It has been said that the so-called Public Option in the present house bill draft is a watered down version Hacker’s, a professor at Berkeley, original proposal.

Hacker predicted that his proposed public program would so closely resemble Medicare that it would be able to set its premiums far below those of other insurance companies and enroll at least half the non-elderly population Hacker’s “Health Care for America Plan” would enroll 129 million people (50 percent of the nonelderly population) and cut the uninsured to 2 million. Through it, roughly half of non-elderly Americans would have access to a good public insurance plan…. A single national insurance pool covering nearly half the population would create huge administrative efficiencies.

Proponent’s estimates suggest that roughly half of non-elderly Americans would remain in workplace health insurance, with the other half enrolled in Health Care for America…. A single national insurance pool covering nearly half the population would create huge administrative efficiencies…. Because Medicare and Health Care for America would bargain jointly for lower prices …, they would have enormous combined leverage to hold down costs.

Hacker’s version of the “public option” would, as of 2007 would have: enrolled 129 million enrollees (or 50 percent of the non-elderly); Have overhead costs equal to 3 percent of expenditures; Pay hospitals 26 percent less and doctors 17 percent less than the insurance industry (but these discounts would be offset to some degree by increases in payments to providers treating former Medicaid enrollees); and, Set its premiums 23 below those of the average insurance company.

His argument was that Medicare was a great success. However Medicare started with a potential large population base from those over the age of 65. The base for those eligible for the Public Option is not captive and has to be reached with the setting up of administrative offices, advertising campaigns, and enlisting providers willing to accept lower income. No consideration was given to the fact that Medicare has been plagued by excessive administrative cost perhaps due to the fact that the programs are contracted out to the private sector.

However, according to the Congressional Budget Office, the “public option” proposed in the House “tri-committee” bill might insure 10 million people and would leave 16 to 17 million people uninsured. The CBO said its estimate of 10 million for the House bill was highly uncertain, which is not surprising given how vaguely the House legislation describes the “public option.” I have not considered the Senate version which is a non entity.

According to the CBO, the “public option” in the House bill (10 million enrollees (maybe!); 17 million people left uninsured) will have virtually no effect on health care costs, which means the “public options” cannot, by themselves, have any effect on the number of uninsured.

Never the less, many facets to this portion of the program have aroused the antagonism of various sectors of the population. Naturally the insurance companies, the leading antagonists, do not want a competitor who will be subsidized by the government at a lower rate than the insurers can operate. That is understandable, private insurance companies are in the business to make money. Don’t you and every one of us have an occupation in order to make money? The question is what is realistic and what is excessive. That even if the Feds establish this program the government subsidy will come from taxes. In effect there will be no true lowering of the costs of health care, just shifting-and hiding- the source of paying for the insurance.

I quote from a source that I do not remember; Supporters of the "public option" think it can achieve efficiencies allowing it to under price existing insurers. But efficiency is to government programs what barbecue sauce is to an ice-cream sundae: not a typical component. Nor is there any reason to think Washington can administer health insurance with appreciably lower overhead than private companies.Medicare supposedly does so, but that is partly because it doesn't have to engage in marketing to attract customers, which this program would. It also spends less than private companies combating fraud and unwarranted treatments -- a type of monitoring that spends dollars while saving more.

As the Congressional Budget Office has pointed out, "The traditional fee-for-service Medicare program does relatively little to manage benefits, which tends to reduce its administrative costs but may raise its overall spending relative to a more tightly managed approach." False economies are one reason Medicare has done a poor job of controlling costs.Yes the so called Public Option as presently constituted presents many unanswered questions as to its potential in solving the problem of the uninsured or if it will be a step on the road to compulsory Federal run Health Care.

Yes there have been proposed other alternatives. An alternative to the Public Option, which has been offered as a compromise is the so-called Regional Nonprofit Cooperatives. Uwe Reinhardt,Princeton professor of Economics and Social Sciences, has been promoting them for over 30 years. He has based his opinions on the German healthcare system about which he has become enamored. such as the Regional Health Cooperatives.

The other alternate, which will be unacceptable to a large segment of the public, is a single-payer government operating healthcare program for. Healthcare. Providers such as the AMA representing the physicians, the pharmaceutical houses, and the insurance companies are all blamed for opposition to that program.

Tuesday, August 25, 2009

1-We blogers receive many comments about our blogs and wish more readers would send their own thoughts. We do publish all that are in good taste and related even peripherally to the blog. Some comments are very profound and reflect the authors thoughts about a particular subject. Others are supportive for the bloger and are appreciated. Still others, fortunately less frequent, blast the bloger n his position. Those too are posted because because they reflect the concerns of a sizable segment of the population. There are some that seem to be just propaganda for an individual with a chip on his shoulder. Those would be better served if the writer would have a blog of his/her own, and will not be given exposure on this blog. There are a rare number that are vituperative without any real facts. They too will go into the trash.

Of the many I have received, I think this one is the commentary of the year. It was sent in response to my blog "Weird Potpourri" about how one must access the Mayor's Office. I thank Jim Pivnichny for his original blog . Binkysmst said... hmmm ring a bell and someone comes out to ask what you want....sounds a bit like the Wizard of Oz...Isn't a sense of humor great. Sometimes I too think Plainfield's government is fantasy.

2-Less than two weeks until Labor Day. We can look forward to 8 weeks of political prattle,squawk,and smirch. May the truth emerge and the voters cast their ballots aster scrutiny of facts rather than binding to party and ethnic affiliations. That would be too much to hope for but it would be for every one's benefit if Democracy worked as envisioned.

3-It is my opinion that it would be less confusing for our taxpayers who receive their tax bill based on a Calendar year if the City discarded the Fiscal Year in use and returned to the Calendar Year finance formula. I know that some members of the Council agree with me, and I am sure that others would if they considered the change.

However the City Administrator has stated that it would be difficult for Plainfield to do so. Strange, other adjacent communities have already or are in the process of reverting to the Calendar format. They have found no problem to discourage them from being sensible.

To be sure the difficulties in producing a budget will still continue if the Administration waits to know what the Extraordinary State Aid will be. Yet there is no need to procrastinate for 8 months. A realistic estimate can be used and the budget amended if need be when the actual amount becomes available.

4-The Government has just released the news that there will be no COLA adjustment for Social Security this year. I do not know how the COLA is calculated, but in the past few years the adjustments have been below the true rise in the cost of living. Certainly, there is no relationship between the built in raises in municipal workers contracts and Social Security.

With the annual rise in the Medicare deduction (insurance premium) and the greater increase in the cost of the associated prescription plans many Seniors will receive a smaller monthly check in 2010 than they get this year. Even with this years larger than usual COLA adjustment my wife received less than last year and next year will be worse.

An unfortunate fact of the present Medicare attached prescription plans which are products of the commercial insurance companies but the premium is deducted from Social Security is that most savings are in generics only. Level 2 and Level 3 drugs require a higher copay and in some of the level 4 medications the insurance pays less than half. Sure there is a saving but in actual dollars it can be insufficient since many drugs unique to geriatric patients such as those used in treating dementia or depression fall into levels 3 & 4. And then there is the "donut" where the patient is responsible for 100% of the medication costs.

When and if I get around to write about Medicare and the Public Option or one payer plans I will further expand on this subject. In the mean time I plan by tomorrow to post something on the Public Option question.

Monday, August 24, 2009

Sunday is supposed to be a day of rest and I used it to read all three newspapers. Both the Star-Ledger of the Times devoted large portions of the Op Ed pages to discuss the health care reform legislation. If you are interested do read them,both the Editorials and Op Ed pages in both. The Times articles are spread over several pages in its "Week in Review" section as well as news sections. Don't ignore the letters. Now on to my opinion.

Justifiably the criticism of late has been a result of the President's waffling on his stance over the public option and concerns about the care for the elderly . Despite the President's repeated affirmation that for the elderly there would be no rationing of care , the language in the bills and the words of the Speaker of the House seem to promote the concept of savings at the expense of the elderly. Indeed Obama is trying to be the consummate politician by reassuring and agreeing with both polarized parties. That can be fatal for the reformation in the long run, and also for his Presidency.

There are severalOp Ed, articles, including one in the New York Times on August 17 by Richard Dooling, thatcriticize the degree of extensive care given to senior citizens. These writers advocate that the money saved there could better be used in treating the young. Somehow, he and other social planners find little value in old age. This is reminiscence of many Science Fiction stories of the past in which societies eliminatyed the elderly as they became a dredge on resources. Can truth be the same as fiction?

As a very soon to be a nonagenarian, I for one resent being considered useless and not worth receiving hospital care of any major substance because ofage. I am not advocating that prolong care be given when recovery with any acceptable quality of life is not present.

I agree that great deals of resources are wasted. When it is time to die that is one thing, but to be denying individuals with a good quality of life and continued productivity the right to live is another.

It is true that many of the patients who are on life support systems are so because relatives insist. To do otherwise or to deny that request has been the basis of most lawsuits, therefore Hospitals discourages the removal of life support.

The choice of life should be a personal decision. While it is true that a comatose or incoherent individual can’t make a decision at that point the mechanism exists for their wishes to be followed. All the elderly should execute a living will and also designate a person to act for them if they were incapacitated.

Whether the Bill the Presidents signs will clarify this issue waits to be seen.As I have written earlier I expect that there will be some kind of legislation enacted this year, after the return of Congress. To get it done the President will have to make compromises. None will satisfy powerful groups and it will be difficult to prevent the ultimate bill from being emasculated.

This will be the first of several posts before Labor Day on the Health Care Reform including the "Public Option", Medicare, and where economies can come from. Don't hold your breath.

Saturday, August 22, 2009

Rather then dwell on Friday night's mele at the teen dance at the YMCA, or the shootings (3) on West Front St. I am going back into memory lane.

In 1950 the Muhlenberg's Medical Staff was organized into various departments characteristic of all hospitals in that era. Today the same basic but expanded structure exists.

What was characteristic of the 1950 staff that with the exception of Merton Griswold non of the physicians were board certified. Board Certification was just beginning to become a criteria of training. By the time I became President of the Staff Muhlenberg was one of the few local area hospitals that required every applicant for a staff appointment to either be certified or eligible pending taking the tests in their specialty.

But in 1950 the active staff members had all started their practice as general practitioners, and gradually added competency in a specialty. Many had served in the armed forces during WWII, and had 4 years to reestablish themselves.

The Department of General Surgery consisted of;

4 Senior Attending Physicians-

Ben Glass,

Leo Salvatii,

Charlie Hoffman,

Charlie Steffens

4 Junior Attending Surgeons-

John Cannis,

Dick Peters,

Ted O'Brien

Art Seybold;

4 Assistant Junior Surgeons-

Bruce Caroll,

John Nevius,

Mert Griswold

Frank Romano.

Of the Seniors, Steffens and Glass were prob ably the most skilled. Charlie Hoffman who had been a colonel during the war was noted for his bedside manner especially with "little old ladies"Leo Salvatti, Eugene's uncle, was in Westfield. Leo was a little gruff and bombastic but a wonderful human being.

Of the Junior Attendings; John Cannis had the advantage of not having been in service. John was notorious for making rounds during visiting hours and being sure to be paged several times so that the public became acquainted with his name. E.J. O'Brien was a outgoing Irishman who rapidly built up a large family practice. He probably did as many tonsillectomies as some of the pure EENT specialists. His obstetrical practice was second only to the Obstetricians. He was well aware of his limitations and did not hesitate to either have a consultant or refer his patient to a Senior Attending in that field. Art Seybold was very quiet , and Dick Peters also established a large general practice but was not doing obstetrics.

The Assistant Junior Attendings; Bruce Carroll after serving in both WWII and the Korean War developed an extreme interest in Vascular Surgery. He did some training under Crawford in Texas, one of the leading Heart Surgeons of that era and had a close relationship with him. Frank Romano had a general practice in Dunellen and assisted Dr Fitch the Neurosurgeon. Griswold the only board certified gradual limited his practice to plastic surgery. Nevius also had a general family practice and like all of us at that time delivered babies.

There were other doctors on the staff heads of subspecialty departments that did major operations in general surgery. None attempted to operate in the Chest.

The first two items were written late Friday night and were to be the sole post. I considered the need to have to ring a bell to seek entry to our Mayor's office. It should be readily accessible unless no one is present. No ifs, ands, or buts.

I also thought it weird that Green should post a letter and dated 8/18/2009 announcing the granting of ARRA-CSBG funds when I had already printed it along with other "stimulus" data from what looked like a Power Point slides on 8/8/09. Whether the slides were for a presentation at the 8/10/09 Council Agenda Setting Session or for something earlier is not known by me. Obviously, the City Administration was aware of the Grant at least 2 weeks before JG posted it as news.

The other stuff was added just before posting the blog as a matter of interest. The fact that Scotland has semi-autonomy from England is interesting. How independent it can act is also of interest. It is believed that the Scottish Courts and Government were instructed to act rather than the British Government in order to prevent criticism of the Prime Minister and Cabinet.

The third addition was an explanation of my professional status. You all know the problems with having prescriptions renewed if not OK'd by the doctor's office and the problems getting that OK to the druggist. I can still write prescription's but do so only for those my doctor has recommended.

I save their office trouble, myself time. The restricted license is several hundred dollars less than a full license. However to prescribe medications that are listed under "Controlled Dangerous Substances" list which is much larger than narcotics a separate license from the State and one from the Federal Government is required. The state is annual and the Federal one costs $500.00 for 3 years.

I could go on an write an essay about the costs of running a doctor's office today and how rules and regulations and insurance company demands inflate office operating expenses and the cost of health care. The latest weird requirement was for doctor's offices to have a photo ID of the patient in their file. I haven't had the time to find out the whys and whatfores of this rule.

Jim Pivnichny wrote in his blog that to access the Mayor's office you have to ring a bell. Then someone will open the door to find out what you want. I suppose that is security, a great concern of this administration.

It was some time before 2006 that I had occasion to visit the Mayor's office. I can remember being able to walk in, note if the Mayor was in, and stop at the secretary's desk. Of course since 9/11 2001 and the Republican Administration times have changed.

JERRY posts "GOOD NEWS": Friday the Assemblyman posted a letter announcing a "$267,909 award from the ARRA – CSBG* – Non-Discretionary program. This award will provide funds for employment services for low-income individuals at or below 200% of the federal poverty guidelines in Plainfield City'.

Now we must find out how and by what agency the funds will be used. This is stimulus funds and was posted last month on the city site on the applications for ARRA funds as having been awarded as a 'Community Services Block Grant".

Jerry why is it now news? If this could be posted a month ago to demonstrate what the city administration is doing to receive "stimulus money" why is the state writing you a letter now? According to the posting on the city site the funds were not requested meaning amount but as "N/A Formula Grant". I hope you are not taking credit.

Food (or Oil) for thought: Today's Times has an article raising the question that Scotland's compassionate release of the PANAM 103 bomber was more to expedite an oil deal that was supposed to have been implemented 5 years ago. Note that it was the Scottish government that authorized the release. Scotland has a semi-autonomous Government subject to the overall British Government.

Does terrorism and governments coexist? Judge from this article in today's Times "Iran’s defense minister nominee is wanted in the bombing of a Jewish center in Buenos Aires, confronting Iran with another challenge to its reputation". And Obama say we can have normal relationships with Iran. So could France, England and Poland have had with Hitler's Germany in1940.

Clarification: In a Comment to Dan yesterday who was suffering from a cold I wrote"I am not licensed to treat patients.". I still have my license as a physician in New Jersey which was granted in 1946. Since I stopped all activity with patients on 1/1/2001 I have held a restricted license that prohibits me from treating patients outside my family. The last 10 years of my active medical life was spent in an administrative roll as the Medical Director of the CJIPA. Part of my job was to see that the doctor's charge s were fair and on the other side to make sure the insurance company was not cheating the patients or the doctors. The latter was the most difficult because Aetna and Cigna were always attempting not to pay for treatments or tests.

The Great Falls in Paterson, on the Passaic River, is the 2nd highest waterfall on the East Coast of the US.

You know you're from Jersey when . .You don't think of fruit when people mention "The Oranges ."You know that it's called Great Adventure, not Six Flags.A good, quick breakfast is a hard roll with butter.You've known the way to Seaside Heights since you were seven.You've eaten at a diner, when you were stoned or drunk, at 3 A.M.You know that the state isn't one big oil refinery.At least three people in your family still love Bruce Springsteen, andyou know the town Jon Bon Jovi is from. You know what a "jug handle" is.You know that WaWa is a convenience store.You know that the state isn't all farmland.

You know that there are no "beaches" in New Jersey --there's the shore--and you don't go "to the shore," you go "down the shore." And when you are there, you're not "at the shore"; you are "down the shore."

You know how to properly negotiate a circle.You knew that the last sentence had to do with driving.

You know that this is the only "New" state that doesn't require"New" to identify it (try . . Mexico . . .. York ..! . . Hampshire-- doesn't work, does it?).

You know that a " White Castle " is the name of BOTH a fast food chain AND a fast food sandwich.

You consider putting mayo on a corned beef sandwich a sacrilege.

You don't think "What exit?" is very funny.

You know that people from the 609 area code are "a little different." Yes they are!

You know that no respectable New Jerseyan goes to Princeton --that's for out-of-staters.

The Jets-Giants game has started fights at your school or local bar.

You live within 20 minutes of at least three different malls.

You refer to all highways and interstates by their numbers.

Every year you have at least one kid in your class named Tony.

You know the location of every clip shown in theSopranos opening credits.

You've gotten on the wrong highway trying to get out of the mall.

You know that people from North Jersey go to Seaside Heights, and people from Central Jersey go to Belmar, and people from South Jersey go to Wildwood.It can be no other way.

You weren't raised in New Jersey --you were raised in either North Jersey, Central Jersey or South Jersey. You don't consider Newark or Camden to actually be part of the state.

You remember the stores Korvette's, Two Guys, Rickel's, Channel, Bamberger's and Orbach's.

You also remember Palisades Amusement Park. You've had a boardwalk cheese steak and vinegar fries.

August heat is to blame. I had spent the day reading a good book and downloading to read the 176 pages of Plainfield's Master Plan.Therefore,I will leave the world of blogs to others today-at least for early morning.

By the way, JG posted a letter from the mayor of Linden. I hope that he (JG) will let us in on what action he proposes. Otherwise, what does this have to do with Plainfield?

Thursday, August 20, 2009

No longer do I daily check the obituary page in the Courier for notices about my peers for there are very very few left. However, I still check for old patients , old friends. Alas too many have moved away and no longer live in the area.

Today (Thursday) there was an obituary that made me sad; Dolores Spock age 49. too young.

Dolores was a wonderful caring woman. She was a RN who ran my office in the early 80s. She was compassionate and personally interested in all our patients, treating every one like a human being. I am convinced that many patients came because of her and not the doctor. For more than a decade after I had retired former patients, who I would run into at the markets etc., would ask me if I had heard from her, such was the impact she had on my practice.

I was most fortunate to have Dolores along with other wonderful long time office nurses; Barbara Wilson, Dorothy Mahalic, Nancy Bean, Ruth Latario as an essential part of my practice for over 40 years. We as a team could not exist in today's medical atmosphere.

60 years ago Muhlenberg Hospital recorded 97577 patient days of which 21% were ward patient days, 69% semi-private and 10% private. The economy was good even five years after the war's end. In 1941, the ward patient days were amounted to 41% of the total.

There were three large multi-bed rooms for female medical and surgical patients on the first floor of the newer East building and the same number on the fourth floor for male patients. Ward obstetrical patients were in a small wing between the the East building and the admissions building off the corridor than connected both both with the older West building.

Without air conditioning the temperature on the fourth floor which was under a flat roof often was over a 100% on days like the past few. Certainly the patients on that floor must have felt that they had reached Hell.

HEALTH CARE REFORM:

One of the most controversial issues over the present proposed bills is the end of life consultation issue ,which some zealots claim it is aimed at euthanasia. This issued has caused the AARP which has supported Obama's initiative to lose a substantial number of members.

Concern has risen among the seniors because Obama has stated that necessary cost reductions would come from tightening up Medicare. That can be accomplished d by reducing administrative costs or services. The fear is augmented by government officials stating that the Swine Flue Vaccine when available will be given to (1) Health Care Professionals,(2) young children,(3) pregnant women, and then to adults ages 17 to 65. Since there is no provision for those over 65 on this schedule it would seem that they are being considered expendable. If the population is markedly reduced that would surely reduce cost expenditures by Medicare.

The Swine Flue Vaccination program with its order of allocation of the vaccine is a form of rationing care. The concern is that the denial of protection from this virus would be carried over to the disapproval of other care needs to the senior population.

The other main issue of the federal supported insurance plans has raised fear that every one will be forced to abandon the private insurers. The potential is there. The talk of State Cooperatives as an alternative raises the specter of government managed care and socialism.

GOVERNOR ELECTION:

So far this has been a campaign negative and often stupid TV ads. Christi has not been impressive and Corzine is a lost cause. Where do we go from here?

Wednesday, August 19, 2009

Although in previous postings I have stated my objections to the various incarnations of the Ordinance that passed on first reading Aug 17, 2009 I would like to clarify, explain, and reiterate my position.

But first to go back to my remark at Council that the "walk on" presentation of this Ordinance was " reactive to a disaster". This Ordinance has remained in the wings pending information to and research by the Council subcommittee on Information Technology. It did not appear as an item of discussion at the overly long Agenda Setting Council Meeting of Aug 10 ,2009. one week earlier. It has been in limbo for months and should have been presented by the normal routine used for introduction of Ordinances, not as something that had to be done without waiting for the next business meeting.

Obviously, despite Dashield's vigorous denial, and supported by Council members, that the stimulus was not the Voice Over failure which left City Hall without public phone access, but an agreement between Council and Administration that it was time to re-introduce it. Was it not the appropriate time a week earlier? What had changed? How naive does the Administration think we the voters are?

I am 100+% in agreement that Plainfield needs a functioning Information Technology Division. Indeed we have needed it for the past three years, but now it has become an urgent priority. Instead of diving into the lake without knowing the water depth by creating a "job"with a title that may not describe what is desired, let us take precautions first and start with the creation of the division. Establish general goals and line of reporting and responsibility. Denote the expected type of jobs in that division and potential budget effect.

I am reproducing the from the Civil Service description for "Information Technology Manager 1 Level 1 the following:JOB CATEGORY SUMMARY,A position in this category typically functions as a manager ofan organizational unit, monitors progress of projects, and implements,monitors, analyzes, and evaluates systems within an organization;consults with system users on system requirements, problems, and application software.

Council President Burney wrote in his blog on Monday: At this point we have built out the infrastructure (wiring, IT center,and electrical upgrades). We now need someone to start to put it alltogether (boldface mine). A simple wish, but a very complex task. Every day we wait, wecontinue to waste tax dollars due to the inefficiency that we now have at City Hall. residents will also benefit: A better web-site, more infoavailable, Council meetings on the web- on demand etc.

MY interpretation is that we first need eitherone of the following Civil Service job descriptions:

These individuals will be able to do the hands on work including integratingall everything with what I believe may be unused equipment in the annex. They will have to be supervised by Dashield for the time being.

If it had not been for Coucilor'sBurney and Storch's informative posting on Monday this Ordinance and the Transit Village study would have been a completely and irresponsible surprise at Council's meeting.

This should again point out to the Council the deficiency created by the monthly only meeting schedule. Plainfield's problem's require more frequent regular meetings, which will be less exhausting, shorter and probably lead to greater depth in considering controversial items. At the September meetings the change back to semi-momthly meetings should at lest be a topic for discussion if not action.

11am: In my concern about the job description not matching what is desired I failed to consider that the various titles used were an attempt to give a Civil Service name to the position. Question, is it a Civil Service position? If not, write the job description and call it what you want; IT Director would be fine under those conditions.

About Me

Over aged, Trying to be "the last angry man".about any and all improprieties of stated interest.For some unknown reason has been listed for years in various editions of "Who's Who"(America, World, Science)
I deny any responsibility for typos, spelling and poor punctuation. Hunt and peck has it faults. Speech transcribing does not seem to be the answer.
Enjoying a second career as a self appointed advocate for the public vz local government excesses.